Elbow Pathologies Flashcards
Define Lateral epicondylitis/epicondylalgia (tennis elbow)
Most common overuse syndrome in the elbow
Tendinopathy involving the extensor muscles of the forearm
Epicondylalgia because no symptoms of tendinopathy
Affects radial nerve as it passes through heads of supinator - neural symptoms
Prevalence of Tennis Elbow
- Affects 1-3% of the population
- Male=Female
- More common in 40s/50s
- ECRB tendon is the most commonly affected; ECRL tendon 2nd most affected; Other common tendons affected = ED, EDM, ECU, supinator
Causes of Tennis Elbow
Repetitive activity involving the extensor tendons of the forearm - musicians, computer users, manual workers, racquet sports (improper training, poor technique, improper equipment)
Risk factors of Tennis Elbow
Smoking
Obesity
Prognosis of Tennis Elbow
○ Most cases are self limiting (90% recover within a year)
○ Re-occurance rate = 8%
○ If do not recover or reoccurance occurs - increased risk of surgery required
Clinical Presentation of Tennis Elbow
○ Pain located around the lateral epicondyle of the elbow, usually radiating in line with the extensors
Insidious onset but often related to H/O overuse without specific trauma
Symptom onset 24-72h after repeated wrist extensor activity
○ Variable pain reported – intermittent / continuous, varying in severity
○ Typically aggravated by resisted wrist / finger extension, forearm supination; Middle finger causes secondary stress to ECRB - ECRB acts as a fixator on 3rd MC
○ Stretching the tendon can also reproduce symptoms, as can gripping - increases compression on common extensor tendon
Eases with rest
Differential diagnosis:
- Radiohumeral bursitis
- Osteochondritis of capitulum
- Posterior Interosseous Nerve (PIN) entrapment - In some cases the radial nerve may become involved as the radial nerve splits into the superficial radial nerve and the posterior interosseous nerve (PIN) at the radiocapitellar joint. Neurological deficit: weakness of posterior interosseous nerve innervated muscles (finger and thumb extensors and abductor pollicis longus)
- Radial tunnel syndrome - PIN may become trapped by pericapsular structures
- Diffuse aching pain over wrist extensor muscles, possibly radiating to the dorsal aspect of the hand, or sharp, shooting pain along the dorsal forearm region. Pain often worse at night
- Rarely, sensory or motor changes
- Pain may be increased by resisted supination, neurodynamic tests, and/or nerve palpation
- Cervical radiculopathy
- Radiation of pain from cervical spine, reproduced by palpation and/or active or passive movements of the cervical spine
- Focal motor, reflex, or sensory changes associated with the affected nerve
- Elbow and forearm overuse injuries
- Medial epicondylitis
Medical Management of Tennis Elbow
NSAIDs - i.e. ibuprofen, naproxen
Corticosteroid Injections
Shockwave Therapy
Surgery - severe cases
Physiotherapy Management of Tennis Elbow
Load Management - stop under/overuse
Exercise:
Stretching:
- Prayer stretch
- Wrist extensor stretch
- Thumb stretch
- Wrist flexion/extension
- Forearm pronation/supination
- Elbow flexion/extension
Wrist extension re-training:
Sensorimotor palm-slide exercise for retraining of wrist extension. With the forearm resting in pronation on a table, the wrist should be slowly extended by sliding the fingertips along the table and lifting the knuckles. Emphasis is placed on avoiding metacarpophalangeal extension and finger flexion. Return to the starting position and repeat 10 times
Strengthening:
Wrist extension exercise can be performed over the edge of a table with elastic tubing or free
weights.
Isometric holds (30-60 seconds in duration)
are advocated for reactive or irritable tendinopathy,
while concentric and eccentric actions should be
performed slowly (4 seconds for each direction),
completing 2 to 3 sets of 10 repetitions for patients
with less irritable or degenerative tendinopathy, only moving in non-painful ROM.
Emphasis is placed on maintaining neutral radialulnar deviation of the wrist (by aligning the middle
metacarpal bone with the long axis of the forearm).
Progression may be achieved by increasing load
or performing the exercises with greater elbow
extension
Wrist radial deviation exercises
Forearm pronation supination exercises
Exercises should also address motor
control impairments, such as dissociation of wrist from finger extension and retraining of wrist alignment during gripping
Brace / Taping - reduce symptoms allowing them to calm down
Education - what the problem is, reduction of aggravating activities
Define Medial Epicondylitis/epicondylalgia (golfers elbow)
Overuse tendinopathy, similar to tennis elbow but affecting the common origin of the flexors and pronators
Affects ulnar nerve passing through heads of FCU - neural symptoms
Prevalence of Golfer’s Elbow
- Prevalence 0.3-1.1%, Female > Male
- Significantly less common than LE (approx. 10% incidence in comparison)
- Age 40-60
- Associated with golf, manual workers
- Involves Pronator Teres and FCR
Prognosis of Golfer’s Elbow
60% recover w/ conservative treatment
Clinical Presentation of Golfer’s Elbow
○ Pain on the medial aspect of the elbow – tender on palpation
○ Aggravated by resisted / repetitive wrist flexion or pronation, valgus (ABD) stress, stretching tendons
○ Aggravated by throwing / gripping
○ Reduced grip strength
○ Can involve ulnar nerve (20%) - Dermatome of ulnar nerve = little finger, ring finger (excluding fingertip)
Medical management of Golfer’s Elbow
NSAIDs
Shockwave Therapy Corticosteroid injections
Surgery
Physiotherapy management of Golfer’s Elbow
Load management - gradual increase
Exercise - Strengthening exercises of wrist flexors and forearm pronators
Education
Taping / bracing - offload to reduce symptoms
Prevalence of proximal humerus #
Normally occurs as a result of a fall
Third most common fractures in the elderly, more common in women (2:1)
Classified depending on how many fragments are displaced:
1-part # = no displacements
2-part # = 1 displacement
3-part # = 2 displacements
4-part # = 3 displacements
